Vasomotor Symptoms and Genitourinary Syndrome of Menopause

Educational Objectives

The goal of this program is to improve the management of menopausal symptoms. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel patients on available therapies for vasomotor symptoms related to menopause.
2. Diagnose genitourinary syndrome of menopause.

Summary

Vasomotor symptoms: associated with physiologic circulatory changes and transient decrease in regional brain flow; include diminished sleep quality, irritability, and concentration challenges; according to a national poll of women, ≈80% of women experiencing menopause have vasomotor symptoms; can last ≤10 yr

Non-pharmacologic therapies: used by ≈50% of women in Western societies; cognitive behavioral therapy, acupuncture, and yoga have been shown to reduce vasomotor symptoms; the speaker suggests black cohosh; in menopausal symptoms research, it has no major side effects; although it is not superior to placebo, it has aided some women; soy also has some symptom relief

Hormone estrogen therapy: the most effective Food and Drug Administration (FDA)-approved treatment for menopausal symptoms; many options are available; according to a position statement from the North American Menopause Society (NAMS), benefits likely outweigh risks for symptomatic women who begin hormone therapy at age <60 yr or <10 yr after menopause onset; management should be individualized and include shared decision-making

Compounded bioidentical compounds: most medical associations that provide guidance to clinicians treating perimenopausal or postmenopausal women recommend against them; the FDA has little or no oversight over bioidentical compounding; contamination or impurities and lack of scientific evidence for efficacy and safety are some of the concerns; speaker refers patients who insist on using bioidentical compounds to colleagues

Other hormonal considerations: there are a variety of options available, depending on the patient's preferences and budget; tissue-selective estrogen complex, which contains the selective estrogen receptor modulator bazedoxifene acetate, is an option

Non-hormonal therapies: although pharmacologic treatments for vasomotor symptoms have been shown in studies to reduce frequency and severity, most are not FDA-approved; serotonin reuptake inhibitors (SSRIs) and serotonin/norepinephrine reuptake inhibitors (SNRIs) have been widely used; low-dose paroxetine (eg, Brisdell) has FDA approval for vasomotor symptoms; other antidepressants, such as venlafaxine, desvenlafaxine, and escitalopram, are used for treating depression and anxiety; even when the indication is not present, they have been proven in research to lessen vasomotor symptoms; gabapentin has been demonstrated in studies to reduce the frequency and severity of vasomotor symptoms; somnolence is a side effect; it may be considered for patients who have difficulty sleeping; other options include clonidine, oxybutynin, and neurokinin-3 receptor antagonists

Genitourinary syndrome of menopause (GSM): affects almost half of postmenopausal women; may be apparent on pelvic exam in ≤85% of postmenopausal women because of decreasing estrogen; first, identify symptoms and then counsel the patient about GSM; according to a 2013 survey, 81% of health care providers do not proactively ask about sexual health or the vagina; another survey found 81% of women are unaware that GSM is a medical condition; patients assume GSM is part of aging and must be accepted; GSM alters the vaginal microbiome and affects the urethra and bladder, causing genital symptoms (eg, dryness, burning, irritation), sexual symptoms (eg, discomfort, pain, dyspareunia), and urinary symptoms (eg, urgency, dysuria, recurrent urinary tract infection [UTI]); clinical signs include vaginal pH >5, fewer superficial cells, an increase in parabasal cells, and repopulation with diverse vaginal flora, all of which contribute to the frequency of UTIs

Management of GSM: lifestyle modifications (eg, regular sexual activity) may help; vaginal moisturizers and lubricants may be beneficial; hormone-free moisturizers do not replenish estrogen but do relieve itching and irritation; rehydrate every few days or 3 or 4 times per week; lubricants are applied only once to reduce friction during vaginal penetration; the World Health Organization recommends an osmolarity of <1200 mOsm/kg of water for these items; hypo- and hyperosmotic products can cause cell damage and impair vaginal tissue; iso-osmotic products are recommended

Local estrogen: available in creams, a ring, tablets, and 10 mcg or 4 mcg vaginal inserts; a Cochrane review concluded all the preparations had similar efficacy; choice depends on patient preference; preferred over systemic estrogen products for patients who only have GSM symptoms; if patients also have vasomotor symptoms, systemic estrogen products may address both; progesterone is not indicated because systemic estrogen levels do not exceed postmenopausal levels with local products; vaginal dehydroepiandrosterone is an applicator-applied ovule; does not have a box warning but does have a precaution for patients concerning breast cancer; ospemifene (Osphena), a selective estrogen receptor modulator, is the only oral product

Vulvovaginal energy-based devices: vaginal carbon dioxide and laser treatments are available, but none are currently approved by the FDA; believed to induce collagen formation, angiogenesis, and epithelial thickening; the FDA issued a warning to the public and clinicians in 2018 regarding vaginal rejuvenation marketing claims, cautioning that efficacy and safety had not been established; NAMS advises against routinely recommending these therapies until sufficient data demonstrating efficacy and safety are available

Nonpharmacologic options: include vaginal stretching, especially for women who are not engaging in penetrative intercourse but wish to resume it, dilators, and stimulation to the vaginal area to increase genital sensation and manage healthy vaginal tissues; the speaker suggests managing GSM and other vaginal pain disorders with a multidisciplinary team; a pelvic floor physical therapist can be a valuable asset

Readings

Karcher C, Sadick N. Vaginal rejuvenation using energy-based devices. Int J Womens Dermatol. 2016 Jun 21;2(3):85-88; Kim HK, Kang SY, Chung YJ, Kim JH, Kim MR. The recent review of the genitourinary syndrome of menopause. J Menopausal Med. 2015 Aug;21(2):65–71; Neff MJ. NAMS releases position statement on the treatment of vasomotor symptoms associated with menopause. Am Fam Physician. 2004 Jul 15;70(2):393-399; Palacios S, Combalia J, Emsellem C, Gaslain Y, Khorsandi D. Therapies for the management of genitourinary syndrome of menopause. Post Reprod Health. 2020 Mar;26(1):32-42; Slaton RM, Champion MN, Palmore KB. A review of paroxetine for the treatment of vasomotor symptoms. J Pharm Pract. 2015 Jun;28(3):266-274; Sussman TA, Kruse ML, Thacker HL, Abraham J. Managing genitourinary syndrome of menopause in breast cancer survivors receiving endocrine therapy. Journal of Oncology Practice. 2019 Jul;15(7):363-370.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Pace serves on the advisory panel for Astellas Pharma US, Mayne, SCYNEXIS, and TherapeuticsMD; has received grant/research support from Pfizer; and serves on the website as HCP for product for Pfizer. Members of the planning committee reported nothing relevant to disclose. In her lecture, Dr. Pace presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Pace was recorded at The Health of Women 2021, held virtually on June 25-August 13, 2021, and presented by the Virginia Commonwealth University Institute for Women's Health. For information on future CME activities from this presenter, please visit Vcu.cloud-cme.com. Audio Digest thanks the speakers and the Virginia Commonwealth University Institute for Women's Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OB690501

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.